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Morning Zen

The 'Murphy bill' (H.R. 2646) fails its own home inspection

When I printed out the text of the Helping Families in Mental Health Crisis Act of 2015, H.R. 2646 (all 173 pages of it) I had to fight the temptation to jump to the particular areas of most interest to me (AOT, HIPAA, among others) and instead, read it the way you would read a novel, from beginning to end, no skipping ahead to look for the good parts, just one page at a time. I encourage all of you to do the same. If you do, you will get a better sense of the tone of the bill, the overall direction of the bill. In effect, you get a feeling for the foundation that the bill is built upon, and it is the foundation that is most critical to the success or failure of any legislative proposal.

Operating from good intentionsIt is important to underscore that Congressman Murphy and the architects of the Helping Families in Mental Health Crisis Act of 2015 (H.R. 2646) are working with the best of intentions. I have had the honor of meeting with the Congressman, and there is no doubt that he cares deeply about this issue. The tragedy at Sandy Hook propelled him to take on mental health reform as a defining issue for his legacy in Congress, and for that, one must applaud him. Members of his staff were incredibly helpful to us early on in our dialogue series by encouraging us to meet with and talk to some of their most ardent supporters. We welcomed the opportunity and after meeting their suggested contacts, have developed some enduring friendships and mutual respect.

Developing relationships with ardent supporters of the Murphy bill underscores the importance of “getting it right” when it comes to the language in this bill. Their stories, along with the stories of the equally passionate individuals who have come out in opposition to the Murphy bill, require us to be vigilant in our assessment. We must analyze it far beyond the sound bytes of political expediency so that both supporters and detractors of the Murphy bill can see movement toward comprehensive mental health reform. Here is the little secret about "divisiveness" between mental health advocates that politicians don’t want you to know. When you get advocates in a room together, away from the political spotlight, more often than not, they are in agreement about the need for a spectrum of mental health supports and services, not one end of the continuum versus the other. We need federal mental health reform legislation to reflect that same continuum approach at the state, tribal and local level.

This bill, as currently written, does not do that. However, don't be deterred, Network faithful. In this post, I will discuss several serious issues with the bill. Make no mistake, while there is plenty that is wrong with the bill, this is also the time for us to rally and share our ideas for how to make the bill better. Take solace in the fact that in a recent meeting between family organization leaders and Congressman Murphy, he was quoted as saying that "this is the time to send in language for improvement." Let's take him up on his offer!

Now is the time to get involved in this discussion. Share your ideas for improvement, and together, we can make this a stronger bill that can lead the way to meaningful mental health reform in America.

Warning: I am forceful in my commentary on the bill. I do so, because, as it is currently written, everyone loses. Network faithful who are Murphy bill supporters lose. Network faithful who are Murphy bill opponents lose. Consider my blunt critique a wake-up call to all of us. What we at the Children's Mental Health Network know better than most is that both supporters and opponents of the Murphy bill need to win if we are going to achieve meaningful mental health reform in America.

Let the tough love begin.

Two “wrongs” don’t make a “right”The Murphy bill rings the bell loudly on SAMHSA’s apparent mission drift away from its legislative required focus on mental illness. On this point, we wholeheartedly agree. It is heartbreaking to hear from so many families with young children who are seriously ill and plead for increased federal focus on the needs of their children with mental illness and the families who care for them. However, the dramatic pendulum shift toward brain research and psychotropic medication to the exclusion of recovery supports is no more “right” than the swing toward “recovery” that gradually gained popularity after the Alcohol, Drug Abuse, and Mental Health Administration (ADAMAHA) was reorganized and became SAMHSA in 1992. In the recent hearing on H.R. 2646, Representative Collins (NY) stated that "no one is suggesting SAMHSA go out of business, but a rebalancing necessary." Unfortunately, this bill is anything but balanced.

The language of hope is abandonedThis bill abandons the language of ‘hope’ and retreats to an earlier time in our history, where we only spoke in the language of ‘disorder’. It would be a shame to see the progress made to de-stigmatize language and provide a sense of hope to those with mental illness wiped away with the stroke of a pen.

A change in the order of emphasis in the preamble of the bill would helpSpeaking of language, one instant fix that would go a long way toward reflecting the thinking of communities across the nation in the year 2015 would be to change the order of priority in the opening sentence. The bill opens with the following sentence (Page 1):

To make available needed psychiatric, psychological, and supportive services for individuals with mental illness and families in mental health crisis, and for other purposes.

If the architects of this bill granted me the wish to change only one thing in the bill, I would change the order of emphasis of this sentence so that it read:

To make available needed supportive, psychological, and psychiatric services for individuals with mental illness and families in mental health crisis, and for other purposes.

A subtle, yet powerful change that would act as a moral compass for all of the language that follows in the bill. Changing the order of priority focus does not diminish the importance of psychiatric services – just puts them in their proper context.

Peer and family support straight out of the 1990’s playbookIf you are a champion for an approach to mental health care that is consumer, family and youth driven, you will probably not like this new version of the Helping Families in Mental Health Crisis Act of 2015.

Sadly, the definition of peer support in this version of the bill does not reflect the forward thinking that has taken place over the past 15 years in understanding family-driven peer support. We have learned much from families about the importance of having family voice that is entirely independent of “supervision of a licensed mental health or substance use treatment professional” (Page 20, line 18), as written in the bill. The importance of recognizing the independent family voice that supplements peer support positions under the supervision of a mental health provider is crucial.

Youth, family and consumer voice on decision-making bodies a mere tokenThe lack of understanding about the importance of youth, family and adult consumer involvement in decision-making forums is evident throughout the bill. We have learned much about the importance of increasing youth, family and consumer voice beyond token representation. Addressing the importance of providing the necessary checks and balances in decision-making bodies by increasing "voice" beyond the professional occupations identified in the bill is of critical importance.

The structural integrity of the bill is inherently damagedIt doesn’t matter where you land on any of the critical issues in the bill; be it AOT, the role of consumer advocacy groups, HIPAA, or where SAMHSA places its priorities. The structural integrity needed to facilitate the implementation of strategies in any of these areas of focus, as written in the bill, is inherently flawed, and thus, will result in a damaged bill doomed to increased federal bureaucracy, wasteful spending, and a dangerous precedent of congressional supervision over executive branch activities.

The Murphy bill attempts to address a management issue through legislationFor the past two years, there has been a constant drumbeat from members of Representative Murphy’s committee that the Administrator of SAMHSA had been a major obstacle to getting committee questions answered about how SAMHSA approaches its responsibilities. Read our review of the recent hearing featuring Administrator Hyde testifying in front of the House committee and you will get a good feel for the level of animosity expressed during the hearing. It is clear that there was no love lost on either side.

Frustrated as they might be, Congress can’t “fire” Administrator Hyde, as the separation of powers between the executive branch and the legislative branch dictates that while Congress has the authority to investigate and allocate funds, the power to replace senior leadership is the purview of the Executive Branch. However, there is nothing to stop Congress from abolishing the position of the SAMHSA Administrator. No position, no Hyde.

Assistant Secretary positionHere is the language in the bill that will effectively give Administrator Hyde her pink slip (Page 14, line 12):

SEC. 102. TRANSFER OF SAMHSA AUTHORITIES. IN GENERAL.—The Secretary of Health and Human Services shall delegate to the Assistant Secretary all duties and authorities that— as of the day before the date of enactment of this Act, were vested in the Administrator of the Substance Abuse and Mental Health Services Administration; and are not terminated by this Act.

In the recent hearing on H.R. 2646, Congressman Murphy said the creation of the Assistant Secretary position would "elevate [the position] in terms of authority (2:28 mark in the video). However, the job duties of the proposed Assistant Secretary are eerily similar to those of the current Administrator. Attempting to further clarify both the rationale behind the creation of the Assistant Secretary position and plans for SAMHSA as an agency, Representative Collins (NY) stated that "no one is suggesting SAMHSA go out of business, but a rebalancing necessary."

Regardless of where you stand on the effectiveness of SAMHSA Administrator Pamela Hyde, addressing those frustrations by attempting to legislate a management issue is just plain wrong. If members of the committee have a problem with the SAMHSA Administrator, then take it up with the HHS Secretary. The Administrators job performance is a management issue, pure and simple, and should be dealt with as such. Management by legislation is foolhardy, dangerous and a waste of the taxpayers money.

The fact that this strategy is not being discussed openly should send chills up your spine. What if a congressional committee was disenchanted with Francis Collins, head of the National Institutes of Health? Would it be wise for them to create a new position, call it something else, but ostensibly doing what Dr. Collins is doing, so that they could get rid of him? And what of the obvious fiscal and bureaucratic changes inherent with such a move? Do we really want to add more layers of bureaucracy just because we are frustrated with a senior level administrator? Creating a new position (Assistant Secretary) in frustration over the difficulties in working with the current administrator is just plain bad law and bad practice.

The question we need to ask ourselves as advocates, and then ask our elected officials, “Is this the most prudent way to deal with a management issue?” Do we need an “extreme makeover” because we are frustrated with the SAMHSA Administrator? Is this the way Congress should address frustration with Executive Branch management issues in the future?

A bill that hearkens back to the ‘good old days'This bill, as currently written, takes us back in time; completely sidestepping the advances in knowledge about the importance of family, consumer and youth involvement as complementary approaches, and sometimes superior, to the advances made in medical science.

The structures, committees and reorganizations suggested in this new version of the Helping Families in Mental Health Crisis Act of 2015 are all designed to funnel through a narrow psychiatric lens that will have a significant impact on the overall direction of federal mental health efforts.

One must be careful not to construe this critique as “anti-psychiatry.” There are amazing psychiatrists throughout the nation who understand and embrace the importance of a community and family-driven approach to mental health care. Unfortunately, the decision-making structures called for in this bill harken back to a much simpler time, when the psychiatric lens was all knowing and all seeing, operating from the perspective of “doing for” rather than “doing with.”

Powerful elements of the psychiatric community are vehement in their disgust with SAMHSA and their desire to right what they see as a wrong in terms of treatment approaches with the mentally ill. Consider this comment from Dr. Jeffrey Lieberman, M.D., Chairman, Department of Psychiatry, Columbia University College of Physicians and Surgeons, at the recent House committee hearing on H.R. 2646 (2:27 mark of the video):

"SAMHSA is a travesty from the psychiatry perspective - Efforts to innovate mental health care have been a disaster, from the academic psychiatric community perspective. SAMHSA is a proxy agency for the anti-psychiatry, for the anti-medical, anti-psychiatry approach to mental health care."

Are the feelings of Dr. Lieberman, presumably representing the entire psychiatric community in America, clear enough for you? Should those feelings shape the direction of mental health reform? When talking to your representatives, you need to be prepared to answer this question. Where are the voices of psychiatrists working at the local level who see the critical importance of a continuum of services and supports that go beyond medication management and supervised care? Both ends of the continuum must be in lock-step with each other.

National Mental Health Policy Laboratory (NMHPL)The Assistant Secretary would handle leading and supervising the National Mental Health Policy Laboratory (NMHPL), which in turn, would be responsible for making decisions about grants approved for implementation. Sounds reasonable, right? But look closer at some of the most troubling guidelines for how decisions would be made (and by whom):

Pre-grant award review(Page 163, Line 13)The bill requires that all grants and contracts be reviewed by the Energy and Commerce Subcommittee on Health 60 days prior to award. This additional requirement is most perplexing and appears to continue the overreach of congressional authority, blurring the lines between the responsibilities of Congress and those of the Executive Branch, through the HHS Secretary.

Review of Peer-review group(Page 165, Line 10)Further chilling is the requirement that the House committee review all lists of members of peer-review groups responsible for reviewing awards.

Emphasis on advisory members who have no relevant experience with the grants being reviewed (Page 164, Line 8)Another confounding requirement is that no grant advisory review members can have been a recipient of any grant, or participated in any program, about which the members are to advise. In other words, this bill suggests that peer review committees be created to include individuals with no context for the work being done. Surely, there is a better way to ensure objectivity than by amphibians rating the quality of proposals submitted by mammals.

One fifth of NMHPL staff appointed by Congress (Page 36, Line 15)This bill proposes that 20 percent of NMHPL staff are congressional appointments. Having the power to dictate the views of one-fifth of the staff would be great for the political party in power. But what happens when that power balance in Congress changes? The havoc created by this one recommendation alone should cause politicians on both sides of the aisle to pause and think carefully about such an Orwellian approach to management.

Cultural inclusive language missing throughoutThe tone and the focus of the bill would change dramatically if the authors were to incorporate a more culturally relevant understanding of what committee structures should look like and how evidence-based practices should be defined. The bill frequently refers to the necessity of making decisions about grant funding based on evidence-based practice. Unfortunately, the composition of the groups identified to make grant funding decisions reflected in the bill do not appear to take into account the need to be culturally inclusive. This is a fundamental flaw in the design of the bill and has far-reaching impact. If not addressed, efforts that emanate from any federal grants coming forth as a result of this bill will fail, as they will perpetuate the disconnect between policy made in isolation and practice that actually takes place in communities across America.

In summaryAs stated at the beginning of this Morning Zen post, it doesn’t matter where you land on any of the key issues in the bill. Proposals for the use of AOT, the role of consumer advocacy groups, HIPAA, or where SAMHSA places its priorities all are doomed to failure. The structural integrity needed to facilitate the implementation of strategies in any of these areas of focus, as written in the bill, is inherently flawed, and thus, will result in a damaged bill destined to increased federal bureaucracy, wasteful spending, and a dangerous precedent of congressional supervision over executive branch activities.

Next steps - Let’s get busy!Okay, now that you have a sense of the termite damage that has infested the foundation of this bill, let’s get to fixin’ it. Look for our upcoming posts on AOT, HIPAA and the importance of addressing cultural inclusion and the rampant disparities inherent in the current mental health delivery system. That ought to give you enough to chew on for the next couple of weeks. Be sure to share these posts with your representatives and advocacy partners as they come available. It is going to be a busy summer for mental health reform.

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Scott Bryant-ComstockPresident & CEOChildren's Mental Health Network

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Comments

Lee Silverman MD

Imagine for a moment that you are a psychiatrist, as I am, at the point of care. For the past 28 years I have devoted most of my waking hours to the needs of those suffering from the effects of mental illness. In most cases, severe mental illness. Do any of you actually consider how challenging such a endeavor can be? Now add to that challenge the horrific, oppressive and at times paralyzingly impact of the endless gamut of policies, procedures, regulation, restrictions, and compliance issues. To appease all of these myriad and at times conflicting mandates from agencies that arguably are misguided and mismanaged while simultaneously trying to heal those persons under my care is not humanly possible. Nor should it be. Yet, the reality is that care providers spend far too much or our time and resources running frantically from one compliance crisis to the next futilely trying to appease all of the regulators. Mental health care has become a fragmented and at times dysfunctional mess. To whatever degree there are persons in charge of this mess, they are the wrong ones. We have lost our way. Psychiatrists like myself, those that actually treat patients, know what is wrong and more importantly how to fix it. But we cannot because we have lost any power, influence or control over this sinking ship. When I have a severely distressed patient sitting with me, perhaps suicidal or agitated and psychotic, do you really want me to be focusing on "value based care"? On "health homes"? On "mental health first aid"? On "cultural competency reflected in the record"? On "individualized treatment plans"? I could go on and on as the list is endless. I am really good at what I do. I was well trained and have a tremendous amount of experience. Please allow me to do my job. I appreciate any help offered, but please respect my opinion and more importantly my expertise that makes such an opinion very relevant. Of course involving the patient and whenever possible their families and support systems in treatment decisions is ideal, but not always fully realizable. And, no, most mental illness is NOT caused by undiagnosed medical issues. Being a patient who has recovered does NOT necessarily make one an expert in the diagnosing and treatment of mental illness. The concept that many mental illnesses are caused by trauma is NOT a new or foreign concept to psychiatrists. Quite the opposite is true, and if you doubt me I encourage you to read Freud's psychoanalytic works that are around a hundred years old. It is great that patients, their families and other stakeholders have found their voices and a place at the table. But have you noticed that I am now without a seat and no one is listening to what I am saying? The pendulum has swung too far. The director of SAMHSA should be a psychiatrist, and one who has extensive experience treating those afflicted with mental illness. One who has the overwhelming support of his or her colleagues. How many hours of course work or training involving the nature and treatment of mental illness goes into attaining a JD or an MBA? I think all of you know the answer to that question. Let's bring back a little sanity to the treatment of mental illness.

Gene

I was in the hospital and it was a nightmare. Psychiatry is so disgusting. For example they knew Risperdal was causing little boys to grow breasts and they covered it up as long as they could to make money. There behavior shows the industry is run by soulless psychopaths.

Candace Aylor, RN, CFP

Thank you for this post, and helping to break it down. As a state and local leader for mental health reforms in Texas, it can be overwhelming to digest issues on a much larger scale such as this.

I am unique, sort of. I advocate as a family member. I am also a nurse. One thing I have realized: there is no us and them, just a perception of divisiveness. Many professionals, clinicians and administrators have their own personal and/or family histories struggling to achieve mental wellness. I've yet to meet a one that decided to get into this industry to get rich, nor to hurt people. However, the path the choose to arive here, in this place we are all working to make things better, that path may include influences of traditions and a way of doing business that does not actually achieve the goals we all originally had when we first stepped on our paths: to help people feel better.

A pervious comment suggests a rationale for supporting continuation of the medical model many communities still utilize is to prevent medical harm through a lack of identification of medical issues facing those with co-occurring struggles to achieve mental wellness. This concerns me for two reasons: 1. The approach described presumes there must be a condition fitting a medical model for identification and treatment of the condition causing the individual to need assistance from a medical professional to achieve mental wellness. 2. This assumes the skills of analysis of labs, signs & symptoms for evidence of a physical health condition cannot be handled by any profession other than a medical doctor.

It seems our most acheivable goal for success would be to eliminate divisiveness as much as possible. I was so utterly shocked to read the comments of Dr. Lieberman in the posting. I have personal experience with psychiatrists opposing my expertise as a parent - I had no idea this was so pervasive an approach as to rise to the top.

The reality from my purview, and those of my colleagues, is that more often if a person is treated with respect, as a fellow human, evaluated from a mindset of determining what may have happened to them rather than what is wrong with them, and offered ways to achieve mental wellness that are truly individualized - They feel more mentally well longer.

Scott, Thank you for an excellent analysis of the basic structure of this legislation. I am on the Board of the National Coalition for MH Recovery and am co-founder of NEC. The NCMHR is adamantly opposed to this new version of Murphy's bill as we were of the last. We are forming a Coaltion of the unwilling and wonder if your Network might join?

An excellent start to revisiting Murphy. However, evidence from outside the drug industry needs to be considered. “Many mental health programs are not staffed with physicians practiced in medical diagnosis and thus are unprepared to detect a large proportion of physical diseases in their patients…California’s state mental health programs fail to detect many diseases that could be causing or exacerbating psychiatric disorders” (1)

In 1995 a study found that from 5–40% of psychiatric patients have medical ailments that would adequately explain their symptoms. (2) The next year, in 1996, Sydney Walker III, M.D., a psychiatrist, in his book, A Dose of Sanity, claimed studies have shown that from 41% to 75% of individuals are initially misdiagnosed, often due to overlooked treatable conditions. (3) In 2009, it was found that up to 25% of mental health patients have medical conditions that exacerbate psychiatric symptoms. (4)
The use of the Koran Algorithm would significantly reduce the number of individuals misdiagnosed, however utilizing other research done since would also reduce the number of people diagnosed with various mental illness and steer them into appropriate treatments.